Competing Pressures for U.S. PEPFAR in Botswana

Botswana has made tremendous strides in the fight against HIV/AIDS in the last decade, supported by the early and important U.S. partnership created through the President’s Emergency Plan for AIDS Relief (PEPFAR). In the next five years, however, that partnership will be tested as the United States and Botswana negotiate a complex, multiyear handoff of PEPFAR-supported HIV/AIDS activities and as U.S. financial assistance is reduced. U.S. funding through PEPFAR is anticipated to decrease from $75 million to a plateau of $35 million by 2016, with an annual reduction in funding of about $10 million per year.

Yet, as pressure mounts for PEPFAR in Botswana to transition, the Obama administration has stepped up expectations for all partner governments through its call for the creation of an “AIDS-free Generation,” in which virtually no children are born with the HIV virus; where teenagers and adults are at far lower risk of becoming infected; and where, if they do acquire HIV, they have access to treatment that helps prevent them from developing AIDS and passing the virus on to others.

Over the past 10 years, Botswana has proved itself a willing and capable PEPFAR partner, and it is among the most promising nations in Africa for achieving these ambitious goals. Botswana’s national program already provides universal access to HIV treatment and prevents most HIV-positive mothers from transmitting the virus to their babies. Yet, as is typical of PEPFAR countries in southern Africa, Botswana also has considerable work to do to prevent new HIV infections. Currently, one of every four adults age 15 to 49 in Botswana is infected with HIV. As such, Botswana is a good setting in which to see whether an AIDS-free Generation is achievable and to better understand what success might require in terms of policy and programmatic innovations, health planning and management capacity, and costs.